UM Nurse (RN)

Career Advocates; Los Angeles (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

Career Advocates in Los Angeles seeks an experienced Clinical Reviewer to conduct complex reviews and coordinate care, ensuring medical necessity and benefit compliance. The role leverages advanced clinical judgment and collaboration with internal and external teams to deliver timely, appropriate care.

Successful candidates will hold an accredited nursing degree (ASN/ADN/BSN/MSN) with knowledge of medical necessity criteria and regulatory guidelines, plus 2+ years in healthcare or managed care.

Qualifications

• Advanced knowledge of medical necessity criteria and regulatory guidelines.
• Minimum two years experience in a healthcare or managed care setting.
• Certification in CCM, URAC, or Managed Care Nursing is a plus.
• Demonstrated leadership and mentoring capabilities.

Responsibilities

• Conduct complex clinical reviews using advanced critical thinking and clinical judgment.
• Serve as a subject matter expert and mentor for LVN staff.
• Ensure health plan performance meets Medicare, Medi-Cal, and commercial benchmarks.
• Act as liaison between internal and external clinical teams to reduce barriers to care.
• Provide feedback on process improvements and contribute to department strategy.
• Review and triage service requests for medical necessity and timeliness.
• Present cases to the Medical Director when further clinical review is warranted.
• Communicate outcomes with providers and members in accordance with regulations.

Skills

Advanced clinical judgment

Leadership & mentoring

Regulatory knowledge

Education

ASN/ADN/BSN/MSN

Bachelor's degree preferred

Job description

This role supports clinical operations by conducting complex clinical reviews and coordinating care to ensure medical necessity and benefit compliance. The selected candidate will use advanced clinical judgment and collaborate with internal and external stakeholders to ensure timely and appropriate care delivery.

Key Responsibilities

• Conduct complex clinical reviews using advanced critical thinking and clinical judgment.
  
• Act as a subject matter expert and mentor for LVN staff.
  
• Ensure health plan performance meets Medicare, Medi-Cal, and commercial benchmarks.
  
• Serve as a liaison between internal and external clinical teams to reduce barriers to care.
  
• Provide feedback on process improvements and contribute to department strategy.
• Support and influence project enhancements related to the Medical Management system.
  
• Review and triage service requests for medical necessity and timeliness.
  
• Present cases to the Medical Director when further clinical review is warranted.
  
• Communicate outcomes with providers and members in accordance with regulations.
  

Required Qualifications

• Graduate of an accredited nursing program (ASN, ADN, BSN, or MSN). Bachelors preferred.
  
• Advanced knowledge of medical necessity criteria and regulatory guidelines.
  
• Minimum two years experience in a healthcare or managed care setting preferred.
  
• Certification in CCM, URAC, or Managed Care Nursing is a plus.
  
• Demonstrated leadership and mentoring capabilities.